There is growing concern about alcohol consumption among women of childbearing age. Studies have estimated that 50% of women, ages 18-44, used alcohol and 12.5 % reported binge drinking in the last month. Because approximately 50% of pregnancies are unplanned and many women do not realize they are pregnant until several weeks or even months after conception, fetal alcohol exposure may occur early in pregnancy, a critical time of increased susceptibility to the effects of alcohol. In addition, Project CHOICES, a study of a preconceptional approach to preventing alcohol-exposed pregnancies (AEP), found that over 70% of the women at risk of AEP were smokers. Given that a substantive body of evidence documents the deleterious effects of smoking while pregnant, interventions to reduce AEP and promote other healthy prenatal behaviors should also target smoking cessation. This randomized controlled study, Project CHOICES+, will determine the efficacy of the Project CHOICES intervention plus a referral to an evidence-based smoking cessation program in reducing the risk of alcohol and tobacco exposed pregnancies. Specifically, we will examine the effect of the Project CHOICES+ intervention compared to Treatment as Usual (TAU) in: reducing alcohol use below established risk levels;increasing consistent use of effective contraception;increasing engagement in smoking cessation treatment and increasing smoking cessation. In addition, our examination of the incremental costs of the CHOICES + intervention (e.g., staff time, materials, administrative services, total medical charges pre- and postintervention) will provide a basis for future cost/benefit analyses that will inform policymakers and healthcare organizations of the potential benefits of implementing Project CHOICES+. Project CHOICES+ will be implemented in the two hospitals and 11 community health clinics of Harris County Hospital District (HCHD), the public healthcare system that serves the approximately 3.86 million residents of Harris County, Texas, the third most populous county in the United States. HCHD's comprehensive electronic medical record (EMR) system will be utilized to facilitate screening, intervention and follow up efforts. Our experienced, multidisciplinary team headed is by the primary investigators from the Texas site of the original Project CHOICES study. It also includes HCHD physicians and administrators who will assure project implementation and integration into standard medical care. Our strong history of implementing programs within HCHD and other healthcare systems will enable us to work closely with family medicine, gynecology, psychiatry, nursing, behavioral health, and other key units to assure successful study implementation. Results from this study will inform and advance future efforts in the service of promoting healthy prenatal behavior and reducing the prevalence of alcohol and tobacco-exposed pregnancies.